Exploring association between place of delivery and newborn care with early-neonatal mortality in Bangladesh

Objective Bangladesh achieved the fourth Millennium Development Goal well ahead of schedule, with a significant reduction in under-5 mortality between 1990 and 2015. However, the reduction in neonatal mortality has been stagnant in recent years. The purpose of this study is to explore the association between place of delivery and newborn care with early neonatal mortality (ENNM), which represents more than 80% of total neonatal mortality in Bangladesh. Methods In this study, 2014 Bangladesh Demographic and Health Survey data were used to assess early neonatal survival in children born in the three years preceding the survey. The roles of place of the delivery and newborn care in ENNM were examined using multivariable logistic regression models adjusted for clustering and relevant socio-economic, pregnancy, and newborn characteristics. Results Between 2012 and 2014, there were 4,624 deliveries in 17,863 sampled households, 39% of which were delivered at health facilities. The estimated early neonatal mortality rate during this period was 15 deaths per 1,000 live births. We found that newborns who had received at least 3 components of essential newborn care (ENC) were 56% less likely to die during the first seven days of their lives compared to their counterparts who received 0–2 components of ENC (aOR: 0.44; 95% CI: 0.24–0.81). In addition, newborns who had received any postnatal care (PNC) were 68% less likely to die in the early neonatal period than those who had not received any PNC (aOR: 0.32; 95% CI: 0.16–0.64). Facility delivery was not significantly associated with the risk of early newborn death in any of the models. Conclusion Our study findings highlight the importance of newborn and postnatal care in preventing early neonatal deaths. Further, findings suggest that increasing the proportion of women who give birth in a healthcare facility is not sufficient to reduce ENNM by itself; to realize the theoretical potential of facility delivery to avert neonatal deaths, we must also ensure quality of care during delivery, guarantee all components of ENC, and provide high-quality early PNC. Therefore, sustained efforts to expand access to high-quality ENC and PNC are needed in health facilities, particularly in facilities serving low-income populations.

1. In response to aggregating 2/3 cycles of data to improve statistical power, the authors mentioned that the proportion of women delivering in health facilities has been increasing over time, affecting the relationship between delivery care and early neonatal mortality. If this is true, why would we believe findings from BDHS 2014 data would reflect the current scenario of the association? The BDHS 2017-18 dataset is already publicly available, and it should only take a couple of days to access the dataset. Then why would be we believe BDHS 2014 dataset is more likely to reflect the current scenario than BDHS 2017-18?
In In the previous version, it was recommended to use an alternative method (e.g., propensity score full-matching, propensity score weighting) as a sensitivity analysis for the main findings.
Since there are very few events and only 2 events per effective degrees of freedom (i.e., 2 EPV), why should we rely only on the logistic regression results? The odds ratio from the logistic regression also often suffers from many major problems (e.g., non-collapsible bias; https://doi.org/10.1177%2F0962280213505804). The authors should provide a strong rationale why they are insisted (i) using the BDHS 2014 dataset but not the BDHS 2017-18 dataset, (ii) relying only on results from a single model instead of sensitivity analysis of the main findings using an alternative model, and (iii) why EPV is not a major concern, or if EPV is a concern why not they consider multiple cycles to improve statistical power and stability of the model.
2. According to Annex 1, PNC and ENC are mediators in the relationship between place of delivery (exposure) and early neonatal mortality (outcome). Adjusting for a mediator leads to decompose the total effect into direct and indirect effects (https://doi.org/10.1093/ije/dyt127). Therefore, the authors should not adjust for PNC and ENC in the same model when exploring the total effect of delivery place on early neonatal mortality. To explore the effect of PNC and ENC on early neonatal mortality, they should run a separate model.
There are some minor issues as well: 1. The title needs to be changed. Considering the study design of BDHS, one can only explore the association of institutional delivery and newborn care with early-neonatal mortality. We need longitudinal studies to conclude whether institutional delivery and newborn care actually prevent early neonatal deaths. One example revised title is "Exploring the association of the place of delivery and newborn care with early-neonatal mortality in Bangladesh". Otherwise, please justify why the term "preventing early-neonatal mortality" is appropriate in the title.
2. The study objective in the Introduction is written as "This study aims to explore the association of the place of delivery and newborn care with ENNM in Bangladesh." However, the aim is different in the Abstract. Please restate and clearly specify the study objective in the Abstract.
3. Pleased drop the sentence from the abstract "Singleton births had 95% lower odds of dying in the first seven days of life compared to twin birth (aOR: 0.05; 95% CI: 0.01-0.16) in the same period." This result is not aligned with the study's objective. Instead, it is the Table 2 fallacy.
4. The conclusion in the Abstract is wrong. Since delivery at the health facility is not associated with early neonatal deaths, how the study findings highlight the importance of newborn and postnatal care in preventing early neonatal deaths? Please clarify.
5. The study's strength "The sample size is also relatively large …" is not true. Considering the extremely rare event, the study's sample size ~4000 is tiny (http://www.vanbelle.org/chapters/webchapter2.pdf; https://doi.org/10.1016/0047-2352(86)90111-X). The authors should restate the argument or provide the rationale for using this as a strength.